| NPI | 1235763905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NH 6115) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 3749) |
| Enumeration Date | 2020-03-02 |
| Last Update Date | 2025-08-21 |